Academic medical centers may dominate teaching and research, but a growing number of suburban and rural facilities are offering more comprehensive, high-quality oncology services
The Baylor Charles A. Sammons Cancer Center draws patients to Dallas from around the world. But patients who would prefer to seek treatment closer to home can increasingly find top-quality cancer care at smaller, community based clinics.
Perhaps no medical diagnosis is more devastating and life-altering than a diagnosis of cancer. Nearly 1.6 million Americans received that bad news in 2011, according to American Cancer Society estimates.
When a cancer diagnosis is delivered, the natural reaction of most patients and families is to try to do everything humanly possible to beat the disease. Typically, that includes demanding the very best cancer care they can possibly find.
One might assume that has driven many patients to large academic medical centers with dedicated, high-profile cancer programs. And why not? When lives are at stake, it seems logical to choose facilities that offer a level of knowledge, expertise and technological resources found in academic institutions.
Yet, in reality, 85 percent of cancer patients are diagnosed and receive initial treatment in community medical centers, according to the National Cancer Institute.
In part, that is because unless patients happen to live nearby, seeking treatment at academic medical centers often means long commutes or even the need to set up temporary residence in the area. In addition, trying to navigate a massive medical center campus in an unfamiliar city can be highly stressful — and that's about the last thing cancer patients need. Studies suggest that stress can weaken the immune system and lead to impaired health or healing.
In the past, cancer centers were out of reach for many smaller hospitals due to the costs of specialized facilities and equipment, and the difficulty of recruiting and retaining experienced oncologists. Now local hospitals increasingly have the option to partner with large, academic medical centers to provide local care, in addition to recruiting independent community oncologists. These affiliations can provide access to a structured, proven and marketable program.
But are cancer patients who seek treatment close to home receiving less quality care? The answer is a resounding "no." Many community cancer centers offer evidence-based quality care, while offering the added comfort and convenience of a familiar local institution, in a location convenient to patients’ homes.
Meanwhile, a recent study by the American Association of Medical Colleges and the American Society of Clinical Oncologists found that the nation will face a shortage of 2,550 to 4,080 oncologists by 2020. Clearly, the demand for cancer care will continue to increase, with a growing chasm between supply and demand. Perhaps that is part of the reason momentum is growing for community cancer care centers.
Another initiative that has put local cancer centers in the spotlight is the Community Cancer Centers Program. Launched by the NCI in 2007, the program is designed to create a network of community cancer centers that supports research, enhances access to care and increases quality for more Americans. The goals of the program, which is ongoing, are to:
In addition to the NCI program, healthcare reform seems likely to increase demand for cancer care. The Association of Community Cancer Centers predicts that reform will have these implications:
The transition to personalized medicine will be another powerful driver of demand for new cancer care services. Oncology care of the future will be both standardized and personalized — standardized in terms of protocols to more consistently deliver quality care; personalized in terms of treatment programs tailored to specific types and stages of cancer, as well as patients’ own health records, medical histories, and even their biology and DNA.
In addition to growing demand, there is usually a compelling business case for community cancer centers. Cancer treatment programs tend to be one of the most profitable service lines providers offer.
Indeed, most community cancer centers successfully weathered the recession and are on a firm financial footing. In a survey released by the ACCC in July 2010, 78 percent of the 84 community cancer centers that responded characterized their program's financial status as "good" or "very good."
"Community cancer centers really complement large academic cancer centers," Ms. Bowers says. "AMCs do bench research best. Community and regional cancer centers are most known for translational research and clinical care. However, the shortage of providers in smaller communities can present a problem, especially when people need daily care such as radiation therapy."
There are many benefits to community cancer centers, says Steven Paulson, MD, chairman and president of Texas Oncology in Dallas. "Large cancer centers play a key role in research and might be better at treating unusual types of cancer," Dr. Paulson says. "But community cancer centers are designed to be more accessible to the average patient and are often staffed by physicians who are 100 percent devoted to clinical care."
"AMCs and community cancer centers peacefully coexist in most markets. Care is also similar at both types of facilities: there isn’t much evidence that patient outcomes differ between the two facilities," he adds.
Local hospitals might find themselves partnering with big academic centers to provide care rather than recruiting independent, community oncologists. Other hospitals will continue to have community oncologists but, as noted above, many will affiliate with an established program. Additionally, some community oncologists will form large groups that will participate in research and clinical trials and will partner with academia to provide cutting-edge care that they also take to the community.
Regardless of the operational structure, it is vital to assemble the right team from the start to guide the design and construction of the cancer center. In addition to the facility owners, administrators and potential partners, the team should incorporate the perspectives and input of stakeholders such as physicians, nursing staff, technicians and cancer survivors. Those healthcare professionals should be joined by key vendors including the developer or program manager, architect, and general contractor or construction manager.
In addition, third-party developers that are skilled in the new philosophy of cancer care can assist with the selection of like-minded architects, contractors and other partners. They can provide a professional, dedicated management team which will be responsible for the day-to-day operation of the complex medical space, and they can provide leasing expertise, including negotiating with physicians for independent leases.
Healthcare executives note that there are many strategic reasons to use a third-party developer.
"Having a third party finance and own a healthcare facility helps to ensure compliance with the Stark laws against self-referrals," notes Ms. Bowers.
"Days cash on hand is an important metric that is closely watched by credit agencies," adds Wes Huff, director of real estate for Baylor Health Care System. "Even if a System can pay for a new facility using cash and debt, it might choose to preserve cash by using an outside vendor.
"Most healthcare professionals are not interested in being real estate developers. Third-party firms that develop, finance and manage a facility can bring flexibility and creativity when it comes to marketing the space, which is good for the healthcare system and the Healthcare tenants."
Many of those elements were pioneered by the cancer programs of large academic medical centers. But the concepts of healing environments are also being extended to community cancer centers.
Beyond design elements, here are the components that can potentially be housed in a comprehensive cancer center:
Clearly, only large academic cancer centers are likely to include the bulk of what is on this list. For example, with a price tag of $125 million to $200 million or more, proton beam therapy centers are out of reach for all but the largest, most well-funded institutions. Nor would most community cancer centers be likely to include transplants, research and clinical trials or integrated inpatient and outpatient services.
However, community cancer centers can establish viable programs on a much smaller scale that can satisfy most of the demand for services in their market areas. Components can be strategically selected based on the programs' objectives, scope and possible academic affiliations.
On one hand, the system boasts what is arguably one of the most comprehensive cancer care facilities in the nation, the $150 million, 10-story, 459,717 square foot Baylor Charles A. Sammons Cancer Center at Baylor University Medical Center in Dallas. The huge outpatient building, which was developed by Duke Realty, opened in March 2011 and offers treatments for every type of cancer and includes nearly every item described above.
Yet, at the same time, Baylor operates eight other smaller, community based cancers centers, bringing cancer care to Dallas suburbs and small Texas towns ranging from Carrollton to Waxahachie.
Thus the size and scale of cancer centers can vary widely. While some academic cancer centers including the flagship Baylor facility can approach 500,000 square feet, a successful community cancer center can consist of as little as 7,500 square feet. Locations can be on-campus or can be freestanding and community-based.
Most community cancer centers should also be able to rival academic cancer centers in terms of the amenities mentioned above, albeit on a smaller scale. Those amenities can include:
"The need to reduce costs can put a damper on new facilities, but there are still some facilities that have to be built," says Mr. Huff of Baylor Health Care System. "Some are built as a long-term defensive move to defend market share; others are built as a short-term bid to increase revenues. When it comes to the latter type, at Baylor we’re building as fast as we can. We want to better serve our patients while seizing the opportunity to maximize our most profitable operations."
No matter how providers design their new oncology facilities, how they structure their programs and which amenities they offer, one thing is certain: community based facilities will play an increasingly prominent role in the future of cancer care.
Sharon Lleva-Carter is an executive director with Duke Realty and was previously director, design & construction, at Northwestern Memorial Hospital. Richard J. Couturier is vice president, development-South/West, with Duke Realty. For more information, please visit the company's website at www.dukerealty.com/healthcare.
Study Suggests Higher Spending on Cancer in U.S. Leads to Better Care
The Baylor Charles A. Sammons Cancer Center draws patients to Dallas from around the world. But patients who would prefer to seek treatment closer to home can increasingly find top-quality cancer care at smaller, community based clinics.
Perhaps no medical diagnosis is more devastating and life-altering than a diagnosis of cancer. Nearly 1.6 million Americans received that bad news in 2011, according to American Cancer Society estimates.
When a cancer diagnosis is delivered, the natural reaction of most patients and families is to try to do everything humanly possible to beat the disease. Typically, that includes demanding the very best cancer care they can possibly find.
One might assume that has driven many patients to large academic medical centers with dedicated, high-profile cancer programs. And why not? When lives are at stake, it seems logical to choose facilities that offer a level of knowledge, expertise and technological resources found in academic institutions.
Yet, in reality, 85 percent of cancer patients are diagnosed and receive initial treatment in community medical centers, according to the National Cancer Institute.
In part, that is because unless patients happen to live nearby, seeking treatment at academic medical centers often means long commutes or even the need to set up temporary residence in the area. In addition, trying to navigate a massive medical center campus in an unfamiliar city can be highly stressful — and that's about the last thing cancer patients need. Studies suggest that stress can weaken the immune system and lead to impaired health or healing.
In the past, cancer centers were out of reach for many smaller hospitals due to the costs of specialized facilities and equipment, and the difficulty of recruiting and retaining experienced oncologists. Now local hospitals increasingly have the option to partner with large, academic medical centers to provide local care, in addition to recruiting independent community oncologists. These affiliations can provide access to a structured, proven and marketable program.
But are cancer patients who seek treatment close to home receiving less quality care? The answer is a resounding "no." Many community cancer centers offer evidence-based quality care, while offering the added comfort and convenience of a familiar local institution, in a location convenient to patients’ homes.
Growing demand, growing momentum
The number of new cancer cases in the United States will increase 45 percent by 2030, fueled by an aging, increasingly diverse population. That is according to research published by the Journal of Clinical Oncology in 2009. That study by the University of Texas M.D. Anderson Cancer Center projected that there will be 2.3 million new cases of cancer in 2030, up from slightly less than 1.6 million in 2011. The number of cases among minorities will double and cases among seniors will rise by two thirds. In fact, by age 70 or older, men have a 1 in 2 chance of getting cancer and women have a 1 in 3 chance, according to the American Cancer Society.Meanwhile, a recent study by the American Association of Medical Colleges and the American Society of Clinical Oncologists found that the nation will face a shortage of 2,550 to 4,080 oncologists by 2020. Clearly, the demand for cancer care will continue to increase, with a growing chasm between supply and demand. Perhaps that is part of the reason momentum is growing for community cancer care centers.
Another initiative that has put local cancer centers in the spotlight is the Community Cancer Centers Program. Launched by the NCI in 2007, the program is designed to create a network of community cancer centers that supports research, enhances access to care and increases quality for more Americans. The goals of the program, which is ongoing, are to:
- Reduce cancer healthcare disparities.
- Draw more patients into clinical trials in community-based hospitals.
- Prepare facilities for standardizing the collection and storage of voluntarily donated biological specimens for cancer research.
- Link facilities to national computer networks that support basic, clinical and population-based cancer research
- Improve the overall quality of care.
- Improve survivorship, palliative care services and patient advocacy.
In addition to the NCI program, healthcare reform seems likely to increase demand for cancer care. The Association of Community Cancer Centers predicts that reform will have these implications:
- Patients and survivors with existing insurance will have more adequate coverage, including no lifetime limits, fewer annual limits, no rescissions, retiree reinsurance, first dollar coverage of screenings and other preventive services.
- More insurance options will be available for cancer patients and survivors
- Subsidized high-risk pools will be formed that offer age-adjusted standard premiums.
- Dependents up to age 26 will have access to their parents’ plans.
- Patients will have improved information about the value of available options and more standardized information.
- There will be some pressure on insurers to keep premium increases more moderate.
The transition to personalized medicine will be another powerful driver of demand for new cancer care services. Oncology care of the future will be both standardized and personalized — standardized in terms of protocols to more consistently deliver quality care; personalized in terms of treatment programs tailored to specific types and stages of cancer, as well as patients’ own health records, medical histories, and even their biology and DNA.
In addition to growing demand, there is usually a compelling business case for community cancer centers. Cancer treatment programs tend to be one of the most profitable service lines providers offer.
Indeed, most community cancer centers successfully weathered the recession and are on a firm financial footing. In a survey released by the ACCC in July 2010, 78 percent of the 84 community cancer centers that responded characterized their program's financial status as "good" or "very good."
Peaceful coexistence
There is an important role for both community cancer centers and large academic medical centers, according to Donna Bowers, former vice president of oncology services for Dallas-based Baylor Health Care System and now senior vice president-hospital strategy for McKesson Specialty Health, which serves cancer patients through The US Oncology Network."Community cancer centers really complement large academic cancer centers," Ms. Bowers says. "AMCs do bench research best. Community and regional cancer centers are most known for translational research and clinical care. However, the shortage of providers in smaller communities can present a problem, especially when people need daily care such as radiation therapy."
There are many benefits to community cancer centers, says Steven Paulson, MD, chairman and president of Texas Oncology in Dallas. "Large cancer centers play a key role in research and might be better at treating unusual types of cancer," Dr. Paulson says. "But community cancer centers are designed to be more accessible to the average patient and are often staffed by physicians who are 100 percent devoted to clinical care."
"AMCs and community cancer centers peacefully coexist in most markets. Care is also similar at both types of facilities: there isn’t much evidence that patient outcomes differ between the two facilities," he adds.
Where to begin
Cancer centers both large and small have limits when it comes to the amount of capital available for their development. So it is vital for providers to approach each project with clear objectives and realistic expectations regarding what is possible in terms of their business plan and financial position. Likewise, it is important to develop projections regarding the potential market share that the new facility can reasonably capture in light of services offered by potentially competing facilities.Local hospitals might find themselves partnering with big academic centers to provide care rather than recruiting independent, community oncologists. Other hospitals will continue to have community oncologists but, as noted above, many will affiliate with an established program. Additionally, some community oncologists will form large groups that will participate in research and clinical trials and will partner with academia to provide cutting-edge care that they also take to the community.
Regardless of the operational structure, it is vital to assemble the right team from the start to guide the design and construction of the cancer center. In addition to the facility owners, administrators and potential partners, the team should incorporate the perspectives and input of stakeholders such as physicians, nursing staff, technicians and cancer survivors. Those healthcare professionals should be joined by key vendors including the developer or program manager, architect, and general contractor or construction manager.
How to pay for it
Community hospitals with inadequate access to capital — or which simply prefer to put their money into new technologies and other investments in their core business of healthcare delivery — might find it worthwhile to explore partnering with a third-party healthcare real estate firm with experience developing cancer care centers. Such a firm can serve as a long-term partner and advisor, determining necessary resources and developing a plan with appropriate strategies that will meet the hospital's needs. The developer also can provide access to a wide range of financing alternatives that will not burden its client's balance sheet.In addition, third-party developers that are skilled in the new philosophy of cancer care can assist with the selection of like-minded architects, contractors and other partners. They can provide a professional, dedicated management team which will be responsible for the day-to-day operation of the complex medical space, and they can provide leasing expertise, including negotiating with physicians for independent leases.
Healthcare executives note that there are many strategic reasons to use a third-party developer.
"Having a third party finance and own a healthcare facility helps to ensure compliance with the Stark laws against self-referrals," notes Ms. Bowers.
"Days cash on hand is an important metric that is closely watched by credit agencies," adds Wes Huff, director of real estate for Baylor Health Care System. "Even if a System can pay for a new facility using cash and debt, it might choose to preserve cash by using an outside vendor.
"Most healthcare professionals are not interested in being real estate developers. Third-party firms that develop, finance and manage a facility can bring flexibility and creativity when it comes to marketing the space, which is good for the healthcare system and the Healthcare tenants."
What to include
Much has been learned in recent years about ways to contribute to improved patient outcomes through cancer center design. Natural materials like wood and stone, soothing colors, natural light, exterior views, water features, positive distractions like artwork and patterns and healing gardens have become de rigueur design elements because they provide comfort, reduce stress and are believed to promote healing.Many of those elements were pioneered by the cancer programs of large academic medical centers. But the concepts of healing environments are also being extended to community cancer centers.
Beyond design elements, here are the components that can potentially be housed in a comprehensive cancer center:
- Radiation oncology, with technology options including linear accelerators, CyberKnife systems and proton beam therapy
- Chemotherapy and infusion therapy
- Diagnostic imaging
- Urgent care
- Clinics, including general oncology, general outpatient follow up, transplant, multi-disciplinary for additional healthcare needs and physician offices
- Palliative care (which focuses on relieving the pain, symptoms and stress of cancer)
- Research and clinical trials
- Surgery, inpatient and outpatient
- Inpatient beds
- Support space, such as administrative offices, full laboratories and pathology and space for information technology (IT), research and fellowships and publications
Clearly, only large academic cancer centers are likely to include the bulk of what is on this list. For example, with a price tag of $125 million to $200 million or more, proton beam therapy centers are out of reach for all but the largest, most well-funded institutions. Nor would most community cancer centers be likely to include transplants, research and clinical trials or integrated inpatient and outpatient services.
However, community cancer centers can establish viable programs on a much smaller scale that can satisfy most of the demand for services in their market areas. Components can be strategically selected based on the programs' objectives, scope and possible academic affiliations.
Baylor's hub and spoke model
Baylor Health Care System epitomizes the trend of offering cancer care in both the AMC and community setting.On one hand, the system boasts what is arguably one of the most comprehensive cancer care facilities in the nation, the $150 million, 10-story, 459,717 square foot Baylor Charles A. Sammons Cancer Center at Baylor University Medical Center in Dallas. The huge outpatient building, which was developed by Duke Realty, opened in March 2011 and offers treatments for every type of cancer and includes nearly every item described above.
Yet, at the same time, Baylor operates eight other smaller, community based cancers centers, bringing cancer care to Dallas suburbs and small Texas towns ranging from Carrollton to Waxahachie.
Thus the size and scale of cancer centers can vary widely. While some academic cancer centers including the flagship Baylor facility can approach 500,000 square feet, a successful community cancer center can consist of as little as 7,500 square feet. Locations can be on-campus or can be freestanding and community-based.
Most community cancer centers should also be able to rival academic cancer centers in terms of the amenities mentioned above, albeit on a smaller scale. Those amenities can include:
- Convenient parking
- Chapels or areas for meditation
- Complimentary retail, such as cafés, restaurants and other types of food services, as well as shops offering products related to image and wellness, such as wigs, prosthetics, dietary supplements, books, gifts and greeting cards
- Healing gardens and walks, and other outdoor spaces
- Conference and education spaces, such as spaces for libraries, education, psychological counseling, nutrition counseling and support groups
- Pharmacies
- Phlebotomy and lab services
Community centers' growing role
Despite the need for more community based cancer care centers, healthcare executives say they must continue to focus on cutting costs."The need to reduce costs can put a damper on new facilities, but there are still some facilities that have to be built," says Mr. Huff of Baylor Health Care System. "Some are built as a long-term defensive move to defend market share; others are built as a short-term bid to increase revenues. When it comes to the latter type, at Baylor we’re building as fast as we can. We want to better serve our patients while seizing the opportunity to maximize our most profitable operations."
No matter how providers design their new oncology facilities, how they structure their programs and which amenities they offer, one thing is certain: community based facilities will play an increasingly prominent role in the future of cancer care.
Sharon Lleva-Carter is an executive director with Duke Realty and was previously director, design & construction, at Northwestern Memorial Hospital. Richard J. Couturier is vice president, development-South/West, with Duke Realty. For more information, please visit the company's website at www.dukerealty.com/healthcare.
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